Supporting people in crisis

Content warning: This article contains discussions self-harm and suicide.

This article is written for recovery coaches, but the principles and approach apply equally for anyone supporting people living with psychosocial disability, including support coordinators and support workers.

What is a mental health crisis?

 People diagnosed with psychosocial disability will be living with serious and often lifelong mental illness.

While the mental illness may be well managed by the person through a combination of treatment and recovery-oriented practices, mental illness can be episodic, and a mental health crisis can occur. Crisis can arise following a high stress event or trigger or might just happen as part of an underlying illness.

A mental health crisis is when there is a change in a person’s thoughts, feelings, actions, or behaviours which puts themselves or someone else at risk. This might be an acute risk bringing a sense of urgency, or the risk of significant deterioration, where the person is at risk of becoming unable to look after themself or function safely without additional support.

The role of recovery coach in managing crisis

While recovery coaching is not a “crisis service”, recovery coaches can play a part in crisis planning and enacting crisis plans.

Recovery coaches need to understand the following for each person they support:

1.     How the person has stayed safe and been supported in the past and their strengths in these areas

2.     How the person wants to be supported in a crisis

3.     What resources and additional supports they need during a crisis.

These questions are the basis of good crisis or safety planning.

As with all plans we create with people (like a recovery action plan), the crisis or safety plan belongs to the person. A recovery coach’s role is to facilitate reflection, exploration, and review.

Crisis or safety planning conversations require trust and mutual respect. If done well, a crisis planning conversation will build trust and mutual respect.

Developing a recovery action plan

A recovery action plan is a broader plan that explores personal strengths and recovery goals.

 Mental health crises are often part of the recovery journey for people with psychosocial disability. Having a proactive focus through a recovery action plan offers a way to continue the recovery journey with the crises being part, but not all, of the story. Recovery-oriented services are grounded in hope, dignity, and respect. Despite bad days, the people we support can still make progress and create the lives they want.

 Timing matters. Following crises, recovery coaches may need to use their knowledge of the person to judge when it is best to return to a discussion of proactive recovery goals.

Crisis or safety planning

While a barrage of questions can overwhelm someone during a crisis planning conversation, here are some questions that could guide that discussion:

• When you are travelling well, how do you know? What are you doing or noticing?

• Who are some people in your life who support you to stay feeling good and feeling well?

• What are some activities that support you to stay feeling good and well?

• What are some personal strengths that have kept you safe in the past and allowed you to obtain and engage with the extra support you needed?

• When things get challenging, how do you know? What are some things you start doing, stop doing, or notice during these times? Are there any early warning signs you have noticed in the past?

• Are there any triggers? How can we plan to avoid or manage them?

• Are there activities or people that can help get you back to feeling good and well during these times?

• How do you know when it’s time for decisive action and to engage crisis or emergency supports?

• Who are the people, and what are the supports, you need at a time like this?

• What are your service and treatment preferences during these times?

• Do you need anyone, or anything taken care of at home, such as pets or plants?

• Are there activities that help you feel safe while you wait for additional support to arrive?

• How can I best support you as your recovery coach during crisis?

Remember that the person you are supporting has already survived 100% of their dark or hard days. And while there might be things that they want to do differently next time (such as acting sooner, obtaining more support, or choosing different support), the best approach is strengths-based and acknowledges and builds on what has worked in the past.

Observing signs and triggers 

Once a plan is created, the recovery coach should keep their finger on the pulse for any triggers or signs of decline. During conversations, it’s helpful to revisit any triggers and signs of decline that are in the plan. If a recovery coach is concerned by something that wasn’t noted in the plan, it is good to raise it anyway so it can be explored.

Behaviours that might be either in the plan or relevant to a recovery coach include:

• Suicidal thoughts, ideas, or talk

• Sudden changes in behaviour – more risk taking or doing things that seem out of character

• Erratic moods – intense highs and lows 

• Frequent periods of sadness and feeling low

• Withdrawing from others – socially, emotionally, or physically

• Lack of interest in things that once brought joy or a sense of determination

• Frequent and uncharacteristic negative talk – about themselves, their lives, or the future

• Frequently expressing feelings of anger and frustration

• Threatening or aggressive behaviour such as angry outbursts

• Feeling lost, unsure, or hopeless about their situation (especially chronic pain, which is a significant risk factor for suicide)

• Sleep disturbances – sleeping too much or too little or experiencing fatigue

• Increased use of alcohol or other substances

• Confusion, disorientation, or disassociation

• Talking more, or for the first time, about things that do not seem grounded in reality (e.g., sharing unusual theories or feeling like someone or something is after them without reasonable evidence)

• Unusual speech patterns (e.g., seeming to follow word associations or rhymes, rather than clear lines of thought)

Everyone is different, and recovery coaches need to understand each person’s individual signs. Having a sense of what is (un)usual for a person may help those in that person’s life notice a change or decline in mental health.

Crisis management

If a crisis happens, a recovery coach’s goal is to be there for the person. This can offer a sense of support, safety, and control.

 Having a strong recovery-oriented relationship and a crisis or safety plan to refer to and enact can provide that sense of safety and control. Recovery coaches can achieve this by listening non-judgmentally, reassuring the person, and providing clear information about additional support services.

 A helpful acronym to remember is LEAP, which was explored by Dr. Xavier Amador in his book I Am Not Sick, I Don’t Need Help. This framework helps even when people do not recognise that they need additional support. LEAP reminds us that it is time for action and stands for:

• LISTEN – focus on understanding the person’s experience and reflecting it back to them. If the person seems to be experiencing delusions, you don’t have to agree or disagree – just listen and reflect what you have heard back to them.

• EMPATHISE – to convey empathy, you can acknowledge the experience even if you don’t agree with the reasons for the experience. For example, “that sounds really frightening”.

• AGREE – the goal is to connect with the person and obtain additional support. Even if the person does not believe they need additional support and seems to be experiencing hallucinations or delusions, you gain nothing by disagreeing and risk damaging the connection. Agree on what you can (e.g., their experience). Explore the benefits of additional support or treatment and reflect back any benefits they acknowledge.

• PARTNER – you want to aim for agreement on short-term goals. If possible, agree on the next steps and to work on them together. If additional support has been called in, recovery coaches should ask to support the person through the initial engagement.

Sometimes, people won’t agree to additional support or next steps. A recovery coach needs to know their legal responsibilities and be ready to exercise good judgement.

In these situations, it can be useful to make it about the recovery coach’s need for additional assistance. For example, you might say, “I don’t feel able to support you alone at this point. I’m going to reach out and get some additional support”.

The right service to contact might be 000, Lifeline, or primary mental health services. If in doubt and there is a risk of harm to the person or someone else, go with 000. Lifeline can also be contacted while you wait.

Remember your boundaries

Ultimately, recovery coaches are not emergency services. The role of a recovery coach is to offer assistance to plan for crisis and then provide support to enact the plan.

Recovery coaches need to balance building a sense of control and choice during crisis with their need to engage the services that are trained and obliged to respond in emergencies.

Recovery coaches can have honest conversations so that the crisis plan is understood in advance.

After a crisis, it is important to get back to the proactive, recovery-oriented plan and goals. Resting and regrouping are often required following a crisis. A period of support from a recovery coach that is not driven by goals but instead by connection can be a source of comfort for the person who has gone through crisis. Some people might prefer this approach over trying to get back to the recovery action plan too quickly.

Consider what you need after supporting someone through a crisis. Depending on the nature of the crisis, debriefing with a supervisor, Employee Assistance Program representative, psychologist, or counsellor is advised, even if you don’t think you need it. 

If you’re supporting someone with psychosocial disability who doesn’t have a crisis or safety plan, it’s time to get the conversation started and put a plan in place.

While you are at it, make sure you have all the relevant emergency services numbers saved in your phone – this is a handy guide: www.healthdirect.gov.au/crisis-management.

A note on suicide intervention

The risk of suicide can be a type of mental health crisis. The article lists speaking or thinking about suicide as a warning sign to lookout for. However, we do want to acknowledge that, while this article is not incompatible with responding to a crisis that includes the risk of suicide, there are specific and evidence-based models for suicide intervention. The Applied Suicide Intervention Skills Training (ASIST) model is an evidence-based model, and we recommend visiting LivingWorks here if the risk of suicide and suicide intervention is an area you want to learn more about.